Provider Demographics
NPI:1881887487
Name:PADULA, LIBORIO JOSEPH (PHD)
Entity type:Individual
Prefix:
First Name:LIBORIO
Middle Name:JOSEPH
Last Name:PADULA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 51726
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48151-5726
Mailing Address - Country:US
Mailing Address - Phone:734-953-3333
Mailing Address - Fax:
Practice Address - Street 1:30901 PALMER RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48186-9529
Practice Address - Country:US
Practice Address - Phone:734-367-8656
Practice Address - Fax:734-722-9524
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-27
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301003882103T00000X, 103TC0700X, 103TC2200X, 103TF0200X
MI6801015946104100000X, 1041C0700X
MI4101005389106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1508883299OtherWRPH
0H24701Medicare PIN